Provider Demographics
NPI:1417351883
Name:BOOSE, JENNIFER (NP)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:BOOSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 KING RANCH RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-2912
Mailing Address - Country:US
Mailing Address - Phone:662-751-8847
Mailing Address - Fax:
Practice Address - Street 1:3089 S LIBERTY ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-9224
Practice Address - Country:US
Practice Address - Phone:601-813-5249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR869554363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR869554OtherSTATE LICENSE NUMBER